Endoscopic surgery for female urethral stricture linked to higher recurrence risk

Endoscopic surgery was associated with a higher risk of recurrence compared with urethroplasty in women with urethral stricture, according to a retrospective analysis presented during the 2020 International Continence Society online meeting.¹

Using statistical modeling that adjusted for confounding factors, the investigators showed that urethroplasty with local tissue flap (ULT) had a 66% lower risk of stricture recurrence compared with endoscopic surgery (HR, 0.34; P = .003). Similarly, urethroplasty with free graft (UFG) had a 49% lower risk of stricture recurrence versus endoscopic surgery (HR, 0.51; P = .03).

Giulia I. Lane, MD

The researchers also compared ULT and UFG and found that, “There was no difference in recurrence between the 2 types of urethroplasty,” said lead study author Giulia I. Lane, MD, Urology FPMRS Fellow at Michigan Medicine, University of Michigan.

The multi-institutional retrospective cohort study was sponsored by the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). The study enrolled women aged 18 years and older with a diagnosis of urethral stricture who underwent surgery for urethral stricture between 2010 and 2019. Participating sites entered data into a centralized REDCap database.

Women were excluded if they had malignancy or congenitally-related strictures, had strictures that were found and repaired at the time of mesh removal, or had strictures secondary to gender affirming surgery. Women who only underwent office-based procedures were also excluded.

Overall, 1051 charts from 23 institutions were screened. Of these, 248 were extracted. The reasons for excluding the 803 charts were no urethral stricture (219), office dilation only (355), gender affirming surgery (115), urologic malignancy (26), gynecologic malignancy (7), congenital disease (4), surgery date outside observation window (7), missing records (57), and other/unknown (13).

The final cohort comprised 210 charts, after 38 of the extracted charts were excluded. The reasons for these exclusions were no reconstruction (5), surgery date outside observation window (23), gender affirming surgery (1), and excision of mesh at time of surgery (9).

Patient characteristics showed that the majority of patients were white and non-Hispanic. The mean age was 56 years. Women were categorized into 3 groups based on surgery type: endoscopic (36%), ULT (32%), and UFG (32%).

“The relative number of each surgery was equal. There was no difference in demographics between the 3 groups and no difference in follow-up time,” said Lane.

Among the endoscopic surgeries, 88% were cystoscopy with dilation. In the UFG group, 94% were buccal graft with dorsal onlay technique. Among the ULT surgeries, 44% were vaginal advancement flaps and 41% were tubularized vaginal flaps.

Overall, 65 of 180 women had recurrence. This translated to a recurrence-free survival rate of 64% at the median follow-up time of 14.6 months.

“On bivariate analysis, there were significant differences in recurrence between the surgical groups, with endoscopic surgery having the highest rates of recurrence,” said Lane.

At 12 months, 68% of women in the endoscopic group were free from stricture recurrence, compared with 83% in the ULT group and 77% in the UFG group. At 36 months, the recurrence-free rates were 41%, 70%, and 61%, respectively.

Lane also shared data that was not adjusted for confounding factors. The unadjusted 12-month stricture recurrence data showed that 32 in 100 women receiving endoscopy recurred at 12 months, compared with 23 in 100 women receiving UFG, and 17 in 100 women receiving ULT.

Looking forward, Lane said the study results “can help support patients and clinicians as they go through shared decision making for the treatment of female urethral stricture.”

Reference

1. Lane GI, Smith AL, Stambakio H, et al. Treatment of urethral stricture disease in women: a multi-institutional collaborative project from the SUFU research network. Presented during: 2020 the International Continence Society online meeting. November 19-22, 2020.